New Patient Forms Patient Forms Patient InformationPatient Name(Required) First Last Gender(Required)FemaleMalePrefer not to sayBirthday(Required) MM slash DD slash YYYY Social Security Number(Required)Age(Required)Marital StatusMarriedDivorcedWidowedSeperatedSingleMinorParent/Guardian/Spouse Name First Last RelationshipParent/GuardianSpousePatient Address(Required) Street Address Address Line 2 City ZIP Code How Can We Reach You?Preferred Method of ContactEmailPhonePatient Cell Phone(Required)Phone (Parent/Guardian)Work PhoneResponsible Party Email(Required) If patient is a minor, who does patient live with? Both parents Father Mother Guardian Name of Person Responsible for This Account(Required) First Last Social Security NumberDate of Birth MM slash DD slash YYYY EmployerEmployer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands PositionPhonePrimary InsurancePrimary Insurance Holder's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY SSN or I.D. Number(Required)Dental Ins. Co Name(Required)Phone(Required)Group Number(Required)Phone(Required)Secondary InsuranceSecondary Insurance Holder's Name First Last Date of Birth MM slash DD slash YYYY SSN or I.D. NumberDental Ins. Co NamePhoneGroup NumberPhoneEmergency ContactEmergency Contact Name(Required) First Last Relationship to PatientPhone(Required)Family Medical Doctor's Name First Last PhoneGeneral Dentist's Name First Last Last Cleaning Month/YearHow did you hear about us?Whom may we thank for referring you to our office?Have you been seen by another orthodontist? If so, when was your last visit?Do you have friends or relatives who have been to our office?Patient HistoryPlease select the box to indicate you DO have any of the following. Bad Breath Bleeding Gums Blisters on lips or mouth Burning sensation on tongue Chew on one side of mouth CIgarette, pipe or cigar smoking Clicking or jaw popping Dry mouth Fingernail biting Food collection between teeth How often do you brush?How often do you floss?Are your pregnant? Yes No If so, due date MM slash DD slash YYYY List any medications you are currently taking:Allergies Aspirin Barbituates (sleeping pills) Codeine Iodine Signature(Required)I certify that the above questions have been accurately answered. I understand that providing incorrect or insufficient information can be dangerous to my (or my child’s) health.Date(Required) MM slash DD slash YYYY HIPAA Privacy NoticeNOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on April 15, 2003 and will remain in effect until it is amended or replaced by us. It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer. Information on contacting us can be found at the end of this Notice. TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION We will keep your health information confidential, using it only for the following purposes: Treatment: We may use your health information to provide you with our professional services. We have established “minimum” necessary or need to know standards that limit various staff members’ access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement. Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so. Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves out business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances. Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving you , your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgement to disclose only that information directly relevant to your care. We will also use our professional judgement to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise. Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities. Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process. We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed to the extent necessary to prevent a serious threat to your health or safety or that of others. Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to medications, product recalls. disease/infection exposure and to prevent and control disease, injury and/or disability. Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so. HIPAA Notice of Privacy Practices This form does not constitute legal advice and covers only federal, not state, law.Signature(Required)Date(Required) MM slash DD slash YYYY Hansen Orthodontics Privacy NoticeACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish. I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.Please Print Name Here(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY Δ testn
